Impact of evidence-based feeding protocols on clinical outcomes and nutritional delivery in critically ill adults: A systematic review and meta-analysis.

BACKGROUND & AIMS: Evidence-based feeding protocols are used to standardize nutritional care in critically ill adults, but their effects on clinical outcomes remain uncertain. We conducted a systematic review and meta-analysis to evaluate the impact of these protocols on clinical outcomes, and to quantify their effects on nutritional delivery (feeding efficiency).

METHODS

We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, ClinicalTrials.gov, and ICTRP up to December 2025 for randomized controlled trials (RCTs) to compare feeding protocols with usual care in critically ill adults. The primary outcome was the mortality rate. Secondary outcomes included the length of stay in the intensive care unit, hospital length of stay, length of mechanical ventilation, adverse events, pneumonia, vomiting, and organ dysfunction. Additional outcomes were nutritional delivery outcomes. We used the Cochrane Risk of Bias 2 and the GRADE approach to assess the quality and certainty of the evidence. PROSPERO registration: CRD42023391771.

RESULTS

Nine RCTs (5369 patients) were included. Evidence-based feeding protocols resulted in little to no difference in mortality (risk ratio (RR), 0.97; 95% confidence interval (CI), 0.83 to 1.13), length of mechanical ventilation (mean difference (MD), 0.34 days; 95% CI, -1.29 to 1.96), or vomiting (RR, 1.49; 95% CI, 0.68 to 3.27). The protocols likely resulted in little to no difference in adverse events (RR, 0.49; 95% CI, 0.12 to 1.95). The protocols reduced the time to enteral nutrition (EN) initiation and increased daily caloric and protein intake.

CONCLUSION

Evidence-based feeding protocols were associated with improved nutritional delivery but little to no difference in key clinical outcomes in critically ill adults. Future research should focus on the consistent integration of patient-centered core outcome sets alongside the establishment of standardized, prespecified safety and gastrointestinal outcome frameworks.